Emotional Eating and Cardiovascular Risk Factors in the Police Force: The Carolina Blue Project.

There is an association between emotional eating and cardiovascular disease (CVD) risk factors; however, little is known about this association in the police force. This study explores the associations between emotional eating and CVD risk factors in law enforcement officers in North Carolina. Four hundred and five officers completed The Emotional Eating Scale, and 221 of them completed the assessment for CVD-related markers. Descriptive statistics, Pearson's correlation, and multiple linear regression analyses were performed. Emotional eating in response to anger was significantly positively associated with body weight (ß = 1.51, t = 2.07, p = 0.04), diastolic blood pressure (ß = 0.83, t = 2.18, p = 0.03), and mean arterial pressure (ß = 0.84, t = 2.19, p = 0.03) after adjusting for age and use of blood pressure medicine. Emotional eating in response to depression was significantly positively associated with triglycerides (ß = 5.28, t = 2.49, p = 0.02), while the emotional eating in response to anxiety was significantly negatively associated with triglycerides (ß = -11.42, t = -2.64, p = 0.01), after adjusting for age and use of cholesterol medicine. Our findings offer new insights to address emotional eating and lower CVD risk in law enforcement officers.

A Patient-Centered Intervention Reduces Disparities in Remote Monitoring in Patients With Implanted Cardiac Devices.

BACKGROUND: Remote monitoring (RM) is recommended for patients with cardiovascular implantable electronic devices, yet many individuals, especially those living in underserved communities, fail to receive this guideline-directed care. Multilevel interventions that target patient and clinic-level barriers to RM care may be beneficial. OBJECTIVES: This study sought to evaluate a remotely delivered, patient-centered intervention to improve RM activation and adherence and reduce disparities in RM care. METHODS: The intervention provides home delivery of remote monitor, phone-based education, monitor setup, and facilitation of first transmission. A retrospective cohort analysis was performed using RM data from 190,643 patients (71.6 ± 12.7 years of age, 40.5% female) implanted with a pacemaker or defibrillator at 4,195 U.S. clinics between October 2015 and October 2019. Outcomes included RM activation (12 weeks and 1-year postimplantation) and adherence to clinic-scheduled transmissions. Patients receiving a cardiovascular implantable electronic deviceimplant 0 to 730 days before (control group, n = 95,861) and after (intervention group, n = 94,782) intervention launch were compared using logistic regression and generalized estimating equations. Multivariable models included patient, clinic, and neighborhood socioeconomic characteristics. RESULTS: The odds of achieving guideline-recommended activation were significantly higher in the intervention group at 12 weeks (OR: 2.99; 76.7% vs 60.9%; P < 0.001) and 1 year (OR: 3.05; 88.2% vs 79.3%; P < 0.001). Adherence to scheduled transmissions was also higher in the intervention group compared with the control group (OR: 2.18; 89.1% vs 81.9%; P < 0.001). Preintervention disparities in RM activation and adherence were reduced in underserved groups following the intervention. CONCLUSIONS: A remotely delivered patient-centered intervention was associated with earlier activation and improved adherence to RM while reducing disparities in RM care.

Development and Feasibility of a Primary Care Provider Training Intervention to Improve Atrial Fibrillation Management.

The disparities in atrial fibrillation (AF) care are partially attributed to inadequate access to providers with specialized training in AF. Primary care providers (PCPs) are often the sole providers of AF care in under-resourced regions. As such, we sought to create a virtual education intervention for PCPs and to evaluate its impact on the use of stroke risk reduction strategies in patients with AF. A multidisciplinary team mentored PCPs on AF management over 6 months using a virtual case-based training format. Surveys of participant knowledge and confidence in AF care were compared before and after the intervention. Hierarchical logistic regression modeling was used to evaluate change in oral anticoagulation (OAC) therapy in the patients seen by participants before or after training. Of 41 participants trained, 49% worked in family medicine, 41% internal medicine, and 10% general cardiology. Participants attended a mean of 14 1-hour sessions. Overall, the appropriate use of OAC (for CHA2DS2-VASc score ≥1 man, ≥2 women) increased from 37% to 46% (p <0.001) comparing the patients seen before (n = 1,739) versus after (n = 610) intervention. The factors independently associated with appropriate OAC use included participant training (odds ratio [OR] 1.4, p = 0.002) and participant competence in AF management. The factors associated with decreased OAC use included patient age (OR 0.8 per 10 year, p = 0.008) and nonwhite race (OR 0.7, p = 0.028). Provider knowledge and confidence in AF care improved (p <0.001). In conclusion, we show that a virtual PCP training intervention improves the use of stroke risk reduction therapy in outpatients with AF and could be a widely scalable intervention to improve AF care in under-resourced communities.

Sex differences in device-measured physical activity after transcatheter aortic valve replacement.

OBJECTIVE: Physical activity (PA) is an important clinical and quality of life outcome after transcatheter aortic valve replacement (TAVR). We examined the effect of TAVR on objectively measured PA in patients with cardiac implanted electronic devices (CIEDs). METHODS: Daily accelerometer data was obtained from CIEDs. Patients in the University of North Carolina Health System with continuous PA data at least 6 months before TAVR and 12 months after TAVR were included. Changes in activity pre- and post-TAVR were analyzed with linear mixed-effects models using a random intercept for each patient. An interaction term was included to determine differences in PA between men and women pre- and post-TAVR. RESULTS: Of the 306 patients with CIEDs who underwent TAVR, 24,655 patient-days of data from 46 patients, mean age of 82 years old, 44% of whom were female met inclusion criteria. A significant and sustained increase of 14.7% in daily PA was seen after TAVR [10.15 minutes per day, 95% confidence interval (CI) 8.75 to 11.56 P < .001] after adjusting for sex, obesity, race, history of depression, and Charlson Comorbidity Index. Effects were more prominent in women (18.57 [95% CI 16.36 to 20.79, P < .001] minute increase post-TAVR) compared to men (4.51 [95% CI 3.87 to 5.16] minute increase post-TAVR, P < .001). CONCLUSIONS: This study demonstrates PA increases after TAVR with effects more pronounced in women than men. Further, this study highlights the potential use of remote monitoring data for monitoring functional outcomes in device patients after a procedure.

Implementation of an Atrial Fibrillation Decision Aid Care Pathway in the Emergency Department Reduces Atrial Fibrillation Hospitalizations.

BACKGROUND: A straightforward decision aid to guide disposition of atrial fibrillation (AF) patients in the emergency department (ED) was developed for use by ED providers. The implementation of this decision aid in the ED has not been studied. METHODS: A pragmatic stepped-wedge cluster approach for analysis of retrospectively collected electronic health record data was used in which 5 hospitals were selected to commence the intervention at periodic intervals following an initial 1-year baseline assessment with 5 additional hospitals included in the comparison group (all in North Carolina). The primary end point of analysis was hospitalization rate. Hierarchical multivariable logistic regression analyses for admission as a function of the intervention while controlling for prespecified patient and hospital predictors were performed with clustering done at the hospital level. RESULTS: Between October 2017 and May 2020, a total of 11 458 patients (mean age, 71.4; 50.5% female) presented to 1 of the 10 hospitals with a primary diagnosis of AF. Absolute admission rate was reduced from 60.5% to 48.3% following the intervention (odds ratio, 0.83 [95% CI, 0.71-0.97]; P=0.016). After adjusting for covariates, the intervention was associated with a small increased rate of return to the ED for AF within 30 days of the initial presentation (1.6% to 2.7%; hazard ratio, 1.70 [95% CI, 1.26-2.31]; P<0.001). CONCLUSIONS: We demonstrate that implementation of a novel decision aid to guide disposition of patients primary diagnosis of AF presenting to the ED was associated with a reduced admission rate independent of patient and hospital factors. Use of the protocol was associated with a small but significant increase in rate of repeat presentations for AF at 30-day follow-up. Use of a decision aid such as the one described here represents an important tool to reduce unnecessary AF hospitalizations.

Development and Feasibility of a Primary Care Provider Training Intervention to Improve Atrial Fibrillation Management.

Background: Disparities in atrial fibrillation (AF) care are partially attributed to inadequate access to providers with specialized training in AF. Primary care providers (PCPs) are often the sole providers of AF care in under-resourced regions. Objective: To create a virtual education intervention for PCPs and evaluate its impact on use of stroke risk reduction strategies in AF patients. Methods: A multi-disciplinary team mentored PCPs on AF management over 6 months using a virtual case-based training format. Surveys of participant knowledge and confidence in AF care were compared pre- and post-intervention. Hierarchical logistic regression modeling was used to evaluate change in stroke risk reduction therapies among patients seen by participants before or after training. Results: Of 41 participants trained, 49% worked in family medicine, 41% internal medicine, and 10% general cardiology. Participants attended a mean of 14 one-hour sessions. Overall, appropriate use of oral anticoagulation (OAC) therapy (CHA 2 DS 2 -VASc score ≥1 men, ≥2 women) increased from 37% to 46% (p<.001) comparing patients seen pre- (n=1739) to post- (n=610) intervention. Factors independently associated with appropriate OAC use included participant training (OR 1.4, p=.002) and participant competence in AF management (by survey). Factors associated with decreased OAC use included patient age (OR 0.8 per 10 years, p=.008), nonwhite race (OR 0.7, p=.028). Provider knowledge and confidence in AF care both improved (p<.001). Conclusions: A virtual case-based PCP training intervention improved use of stroke risk reduction therapy in outpatients with AF. This widely scalable intervention could improve AF care in under-resourced communities. CONDENSED ABSTRACT: A virtual educational model was developed for primary care providers to improve competency in AF care in their community. Following a 6-month training intervention, the rate of appropriate oral anticoagulation (OAC) therapy among patients cared for by participating providers increased from 37% to 46% (p<.001). Among participants, knowledge and confidence in AF care improved. These findings suggest a virtual AF training intervention can improve PCP competency in AF care. This widely scalable intervention could help improve AF care in under-resourced communities.

Worldwide survey on implantation of and outcomes for conduction system pacing with His bundle and left bundle branch area pacing leads.

BACKGROUND: Adoption and outcomes for conduction system pacing (CSP), which includes His bundle pacing (HBP) or left bundle branch area pacing (LBBAP), in real-world settings are incompletely understood. We sought to describe real-world adoption of CSP lead implantation and subsequent outcomes. METHODS: We performed an online cross-sectional survey on the implantation and outcomes associated with CSP, between November 15, 2020, and February 15, 2021. We described survey responses and reported HBP and LBBAP outcomes for bradycardia pacing and cardiac resynchronization CRT indications, separately. RESULTS: The analysis cohort included 140 institutions, located on 5 continents, who contributed data to the worldwide survey on CSP. Of these, 127 institutions (90.7%) reported experience implanting CSP leads. CSP and overall device implantation volumes were reported by 84 institutions. In 2019, the median proportion of device implants with CSP, HBP, and/or LBBAP leads attempted were 4.4% (interquartile range [IQR], 1.9-12.5%; range, 0.4-100%), 3.3% (IQR, 1.3-7.1%; range, 0.2-87.0%), and 2.5% (IQR, 0.5-24.0%; range, 0.1-55.6%), respectively. For bradycardia pacing indications, HBP leads, as compared to LBBAP leads, had higher reported implant threshold (median [IQR]: 1.5 V [1.3-2.0 V] vs 0.8 V [0.6-1.0 V], p = 0.0008) and lower ventricular sensing (median [IQR]: 4.0 mV [3.0-5.0 mV] vs. 10.0 mV [7.0-12.0 mV], p < 0.0001). CONCLUSION: In conclusion, CSP lead implantation has been broadly adopted but has yet to become the default approach at most surveyed institutions. As the indications and data for CSP continue to evolve, strategies to educate and promote CSP lead implantation at institutions without CSP lead implantation experience would be necessary.

Interhospital Variability in Utilization of Cardioversion for Atrial Fibrillation in the Emergency Department.

The role for direct current cardioversion (DCCV) in the management of atrial fibrillation (AF) in the emergency department (ED) is unclear. Factors associated with DCCV in current practice are not well described, nor is the variation across patients and institutions. All ED encounters with a primary diagnosis of AF were identified from the Nationwide Emergency Department Sample from 2006 to 2017. The independent association of patient and hospital factors with use of DCCV was assessed using multivariable hierarchical logistic regression. The relative contributions of patient, hospital, and unmeasured hospital factors were assessed using reference effect measures methods. Among 1,280,914 visits to 3,264 EDs with primary diagnosis of AF, 31,422 patients (2.4%) underwent DCCV in the ED. History of stroke (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.09 to 0.22, p <0.001) and dementia (OR 0.14, 95% CI 0.10 to 0.19, p <0.001) was associated with lowest odds of DCCV. Comparing patients more likely to receive DCCV (ninety-fifth percentile) with patients with median risk, the influence of unmeasured hospital factors (OR 14.13, 95% CI 12.55 to 16.09) exceeded the contributions of patient (OR 5.66, 95% CI 5.28 to 6.15) and measured hospital factors (OR 3.89, 95% CI 2.87 to 5.60). In conclusion, DCCV use in the ED varied widely across institutions. Disproportionately large unmeasured hospital variation suggests that presenting hospital is the most determinative factor in the use of DCCV for ED management of AF. Clarification is needed on best practices for management of AF in the ED, including the use of DCCV.

Patient Perspectives on Performance of a Smartphone App for Atrial FibrillationSelf-Management.

Introduction: AF self-care requires patients to perform daily self-monitoring for symptoms, practice decision making to address symptom changes, and adhere to prescribed medication, diet, physical activity, and follow-up care. Technology can facilitate these critical self-care behaviors and ultimately improve patient outcomes. We assessed atrial fibrillation (AF) patients' experiences with a smartphone application (app) for AF self-management. Methods: A focus group with 9 AF patients and app users was conducted and analyzed using qualitative research methods. The focus group was recorded, transcribed, and coded using a priori and inductive coding strategies. Participant responses for each code were synthesized to identify primary themes. Results: We identified four superordinate themes from patients' experiences: (1) disconnect between tool and its intended use; (2) app as acknowledged tool for adherence; (3) knowledge as empowerment; (3) motives: self-interest vs supporting research. Results from this qualitative study underscore the need to clarify the app's intended use and to better accommodate patients with different AF experiences. The disconnect between a tool and its intended use can generate frustration for users. Discussion: The study reinforces that participants not only see how the app is a tool for adherence; they also see knowledge they gain via the app as empowering, suggesting a correlation between app use and self-efficacy.

Leveraging a Previously Published Population Pharmacokinetic Model to Predict Rivaroxaban Exposure in Real-World Patients.

Population pharmacokinetic (PK)/pharmacodynamic models are commonly used to inform drug dosing; however, often real-world patients are not well represented in the clinical trial population. We sought to determine how well dosing recommended in the rivaroxaban drug label results in exposure for real-world patients within a reference area under the concentration-time curve (AUC) range. To accomplish this, we assessed the utility of a prior published rivaroxaban population PK model to predict exposure in real-world patients. We used the model to predict rivaroxaban exposure for 230 real-world patients using 3 methods: (1) using patient phenotype information only, (2) using individual post hoc estimates of clearance from the prior model based on single PK samples of rivaroxaban collected at steady state without refitting of the prior model, and (3) using individual post hoc estimates of clearance from the prior model based on PK samples of rivaroxaban collected at steady state after refitting of the prior model. We compared the results across 3 software packages (NONMEM, Phoenix NLME, and Monolix). We found that while the average patient-assigned dosing per the drug label will likely result in the AUC falling within the reference range, AUC for most individual patients will be outside the reference range. When comparing post hoc estimates, the average pairwise percentage differences were all <10% when comparing the software packages, but individual pairwise estimates varied as much as 50%. This study demonstrates the use of a prior published rivaroxaban population PK model to predict exposure in real-world patients.

The Relationship Between Atrial Fibrillation, Mitral Regurgitation, and Heart Failure Subtype: The ARIC Study.

BACKGROUND: Atrial fibrillation (AF) and mitral regurgitation (MR) are closely interrelated in the setting of heart failure (HF). Here we investigate the prevalence and prognostic significance of AF in patients with acute decompensated HF (ADHF) stratified by MR severity. METHODS AND RESULTS: The Atherosclerosis Risk in Communities Study investigated ADHF hospitalizations in residents greater than or equal to 55 years of age in 4 US communities. ADHF cases were stratified by MR severity (none/mild or moderate/severe) and HF subtype (HF with reduced [HFrEF] or preserved [HFpEF] ejection fraction). The odds of AF in patients with increasing MR severity was estimated using multivariable logistic regression, adjusting for age, race, sex, diabetes, hypertension, coronary artery disease, hemodialysis, stroke, and anemia. Cox regression models were used to assess the association of AF with 1-year mortality in patients with HFpEF and HFrEF, stratified by MR severity and adjusted as described, also adjusting for the year of hospitalization. From 2005 to 2014, there were 3,878 ADHF hospitalizations (17,931 weighted). AF was more likely in those with higher MR severity regardless of HF subtype; more so in HFpEF (odds ratio [OR] 1.38, 95% confidence interval [CI], 1.31-1.45) than in HFrEF (OR, 1.19, 95% CI, 1.13-1.25) (interaction P [by HF subtype] < .01). When stratified by HF type, association between AF and 1-year mortality was noted in patients with HFpEF (OR, 1.28, 95% CI 1.04-1.56) but not HFrEF (OR 0.96, 95% CI 0.79-1.16) (interaction by EF subtype, P = .02). CONCLUSIONS: In patients with ADHF, AF prevalence increased with MR severity and this effect was more pronounced in HFpEF compared with HFrEF. AF was associated with an increased 1-year mortality only in patients with HFpEF and concomitant moderate/severe MR. REGISTRATION: NCT00005131, https://clinicaltrials.gov/ct2/show/NCT00005131.

Electrophysiological effects and clinical utility of propafenone in children.

AIM: This retrospective case series study sought to describe the safety and clinical effectiveness of propafenone for the control of arrhythmias in children with and without CHD or cardiomyopathy. METHODS: We reviewed baseline characteristics and subsequent outcomes in a group of 63 children treated with propafenone at 2 sites over a 15-year period Therapy was considered effective if no clinically apparent breakthrough episodes of arrhythmias were noted on the medication. RESULTS: Sixty-three patients (29 males) were initiated on propafenone at a median age of 2.3 years. CHD or cardiomyopathy was noted in 21/63 (33%). There were no significant differences between demographics, clinical backgrounds, antiarrhythmic details, side effect profiles, and outcomes between children with normal hearts and children with CHD or cardiomyopathy. Cardiac depression at the initiation of propafenone was more common amongst children with CHD or cardiomyopathy compared to children with normal hearts. Systemic ventricular function was diminished in 15/63 patients (24%) prior to starting propafenone and improved in 8/15 (53%) of patients once better rhythm control was achieved. Other than one child in whom medication was stopped due to gastroesophageal reflux, no other child experienced significant systemic or cardiac side effects during treatment with propafenone. Propafenone achieved nearly equal success in controlling arrhythmias in both children with normal hearts and children with congenital heart disease or cardiomyopathy (90% versus 86%, p = 0.88). CONCLUSION: Propafenone is a safe and effective antiarrhythmic medication in children.

Immediate and long-term effects of the COVID-19 pandemic and lockdown on physical activity in patients with implanted cardiac devices.

BACKGROUND: Physical activity (PA) is an important determinant of cardiovascular health that may be affected the COVID-19 pandemic. Therefore, we examined the immediate and long-term effects of the pandemic and lockdown on PA in patients with established cardiovascular risk. METHODS: Objectively-measured daily PA data was obtained from cardiovascular implantable electronic devices (CIEDs) from 3453 U.S patients (mean and standard deviations [SD] age, 72.65 [13.24] years; 42% women). Adjusted mixed-effects models stratified by device type were used to compare daily PA from periods in 2020: pre-lockdown (March 1-14), lockdown (March 15 to May 8), and the reopening phase of the pandemic (May 9 to December 31) versus 2019. Patient characteristics and events associated with inactivity during lockdown and the proportion of patients who returned to their 2019 PA-level by the end of reopening phase (December 31, 2020) were examined. RESULTS: Daily PA was significantly lower during the lockdown compared to the same period in 2019 (-15%; p < .0001), especially for pacemaker patients, adults aged <65, and patients more active prior to lockdown. Non-COVID hospitalization and ICD shock were similarly associated with low PA during lockdown (p = .0001). In the reopening phase of the pandemic, PA remained 14.4% lower in the overall sample and only 23% of patients returned to their 2019 PA level by the end of follow-up. CONCLUSIONS: In this large cohort of patients with CIEDs, PA was markedly lower during the lockdown and remained lower for months after restrictions were lifted. Strategies to maintain PA during a national emergency are urgently needed.